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...__.'___•11 • k •:�:•.................•.......w �.sis.vav:vs_v•uv.a._.v._ ].. ..__.1V1.�:.L'JY::.s3-�'.a...... �_..s_�__ ............. ... ............. <br /> , <br /> ® Waste Tire Survey & inspection Report Inspection Report Number <br /> CalRecycle State c California I 1 - 1242355 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> - BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- 2 Inspection Type(Fill one) <br /> Site Suffix: ` J 1 77 O ` Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. pvY�'t`J Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ! 7 Inspected By Inspector <br /> Physical Address <br /> 1?i10 `Clnvcw,Q-�n ��� <br /> CJN gs2lo - <br /> Inspection Date 02— <br /> Time In Time Out <br /> Business Rep Title v O ,PM 3 AM <br /> � PM <br /> 1--- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 0 <br /> o � Active Q Passenger `Generator Q�IA <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned 9 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other k�\a�GS may o -\0mc <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / I]] <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> N <br /> - N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I*In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> f,_�K\ CqNcBch <br /> Inspection Form Included: Q c ,,L�� 'V` <br /> *"e <br /> Comments Included: ! <br /> Business ep's Signature Phone Number Inspe or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � EXAMPLE 1 2 3 <br /> . White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />